format laporan kasus kelolaan icu

LAPORAN KASUS KELOLAAN

ASUHAN KEPERAWATAN PADA KEGAWATDARURATAN

SISTEM.......................................PADA......................

DENGAN...................................................

DI RUANG ICU RSUD TUGUREJO SEMARANG

A. Pengkajian

1. Identitas

Identitas klien

Nama klien :

Umur :

Jenis kelamin :

Alamat :

Tanggal masuk :

Tanggal pengakajian :

Jam :

Diagnosa medis :

2. Keluhan utama :

3. Pengkajian Fokus

a. Pengkajian Primer1) Airway

2) Breathing

1

3) Circulasi

4) Disability

5) Eksposure

b. Pengkajian Sekunder

1) Riwayat Penyakit Sekarang

2

2) Riwayat Penyakit Dahulu

3) Riwayat Penyakit Keluarga

3

4. Pemeriksaan Fisik

1) Kepala dan muka

Inspeksi: .........................................................................................................................

...........................................................................................................................

Palpasi :

.........................................................................................................................................

...........................................................................................................

2) Mata dan telinga

Inspeksi :

.........................................................................................................................................

...........................................................................................................

Palpasi : ..........................................................................................................................

..........................................................................................................................

3) Hidung

Inspeksi :

..........................................................................................................................

Palpasi :

..........................................................................................................................

4) Mulut dan tenggorokan

Inspeksi : ........................................................................................................................

............................................................................................................................

Palpasi : ..........................................................................................................................

..........................................................................................................................

5) Kulit

Inspeksi: .........................................................................................................................

...........................................................................................................................

Palpasi : ...........................................................................................................

4

6) Dada/Jantung/paru

Inspeksi dada :

.....................................................................................................................

...............................................................................................................................

Palpasi paru :

.........................................................................................

.........................................................................................................................................

..................

Auskultasi paru : ..............................................................................................

Perkusi paru : ...................................................................................................

Auskltasi jantung :

.........................................................................................................................................

...........................................................................................................

Palpasi jantung : ..............................................................................................

Perkusi jantung : ..............................................................................................

7) Abdomen

Inspeksi :

..............................................................................................................................

......................................................................................................................

Askultasi : ........................................................................................................

Palpasi :

..............................................................................................................................

......................................................................................................................

Perkusi : ...........................................................................................................

8) Genetalia

5

.........................................................................................................................................

.........................................................................................................................................

...........................................................................................

9) Ekstremitas

Inspeksi :

..............................................................................................................................

......................................................................................................................

Palpasi : ............................................................................................................

10) Parameter umum

Kesadaran :..................

Kesadaran :..................

Vital sign

Tekannan Darah : ............... mmHg

Map :................

Rr : .........x/menit

Hr : .........x/menit

SPO2 : ............

Suhu : .........oC

6

5. Prosedur diagnostik dan laboratorium

Prosedur diagnostik dan laboratorium

Tgl pemeriksaan

Indikasi dan tujuan Hasil Nilai normal Analisa

7

Tanggung Jawab Perawat :

Sebelum :

Sesudah :

Setelah :

8

B. Analisa data

DATA MASALAH ETIOLOGI

9

10

11

1. Diangnosa Keperawatan1. ...................................................................................................................................................................................

2. ...................................................................................................................................................................................

3. ...................................................................................................................................................................................

4. ...................................................................................................................................................................................

5. ...................................................................................................................................................................................

12

C. Nursing Care Plan

No Hari/

Tanggal

Tujuan dan Kreteria Hasil Intervensi Keperawatan Rasional Paraf

13

14

15

D. IMPLEMENTASI

1. Medical Management

IVF, O2 terapi

Medical

managemen

t

Tanggal

Terapi

Penjelasan secara umum Indikasi dan

tujuan

Respon

16

2. Obat – obatan

Nama

obat

Tanggal

Terapi

Cara, dosis,

frekuensi

Cara kerja obat, fungsi

dan klasifikasi

Respon

17

18

3. Diet

Jenis

diit

Tangga

l Terapi

Penjelasan umum Indikasi dan

Tujuan

Makanan

Spesifik

Respon

19

4. Aktifitas dan Latihan

Jenis

aktivitas

dan latihan

Tanggal

Terapi

Penjelasan umum Indikasi dan Tujuan Respon

Klien

20

D. IMPLEMENTASI KEPERAWATAN

Tanggal/

Hari jam

No. Dx Tindakan Keperawatan Respon Klien Paraf

21

22

23

24

25

26

E. EVALUASI

Hari/Tanggal No. Dx Evaluasi Respon Klien Paraf

27

28

F. KESIMPULAN

29